Learn Rehabilitation Therapies to Manage Side Effects of Chronic Graft-versus-Host Disease

Watch demonstrations of stretching and strength-building exercises and adaptive devices that can improve flexibility and strength for GVHD patients who have steroid-induced myopathy (muscle weakness). 

   Download Speaker Slides  

Learn Rehabilitation Therapies to Manage Side Effects of Chronic GVHD

Friday, May 5, 2022

Presenters:

Carly Cappozzo MSOT, OTR/L The University of Texas MD Anderson Cancer Center

Rachael Petrie, MS, OTR/L, MSCS, UofL Health Brown Cancer Center

Paulette Taku PT, DPT, The University of Texas MD Anderson Cancer Center

Presentation is 36 minutes long.

Summary: Chronic graft-versus-host disease (GVHD) can make it difficult to perform many daily activities. This video demonstrates various exercises to improve flexibility and strength, as well as some adaptive devices that can make it easier to do routine daily activities by yourself. Download the speaker slides for printed instructions and illustrations of the exercises and devices demonstrated in the video.

Many thanks to Kadmon, a Sanofi Company, whose support helped make this presentation possible.

Highlights:

  • Steroids used to treat GVHD cause muscle weakness, particularly in the hip and core region, which makes it difficult rise from a seated position, climb stairs and reach overhead. A physical therapy program that includes strength and stretching exercises can help restore muscle strength and flexibility.
  • The most effective way to improve joint stiffness, restricted range of motion and joint contractures is with low intensity stretching held for 30-60 seconds. Mild discomfort while stretching is fine, pain is not.
  • An occupational therapist can provide adaptive devices to help you remain independent, save energy, maintain safety, reduce falls and reduce frustration while doing daily tasks. Splints and casts, fabricated to meet an individual’s needs, can help improve finger, wrist, elbow, shoulder and ankle extension and flexibility.

Exercises Demonstrated in this Video:

(03:45) Isometric Hip Flexion – Alternating to strengthen core muscles.

(04:39): Clamshell to strengthen hip side muscles.

(05:19): Marching to strengthen front hip muscles and make it easier to get up from a chair.

(05:45): Sit-to-Stand to strengthen the core and leg muscles and make it easier to rise from a chair.

(06:19): Bridges to strengthen hip and core muscles and the back.

(09:56): Shoulder Flexion to help with reaching overhead.

(11:27): Chest Opener for chest muscles and front of shoulders.

(12:44): Wrist Extension and Wrist Flexion to help with grasping items, typing on a keyboard and putting weight on hands.

(15:04): Hip External Rotation to help with getting in and out of a vehicle, climbing stairs and reaching your feet.

(16:12): Ankle Dorsiflexion to make it easier to walk without tripping, go up and down stairs and push down on the gas pedal in a car.  

(17:30): Side Body stretch to help with reaching overhead and getting dressed.

(18:16): Trunk Rotation stretch to help you look over your shoulder or behind you, such as when driving a car.

Adaptive Devices Demonstrated in this Video:

(23:46): BirdRock Grabber to reach and pick up small, large and heavy items, and assist with getting dressed.

(22:47): Seeing AI phone app helps with facial recognition, environmental recognition and can read aloud printed material and information contained in barcodes.

(24:37): Freedom Wand makes shaving, showering and toileting easier.

(26:29): Lotion Applicator lets you to apply lotion in hard-to-reach areas without a second person.

(27:41): Slippie Gator and Sock Aid help you put on compression sleeves and stockings.

(31:41): Hand-Based Paddle Orthosis splint to give fingers a good stretch.

(32:38): Hand and Finger Intrinsic Plus removable cast stretches the wrist, fingers and thumb.

(33:13): Custom-made removable casts to improve elbow extension and ankle flexibility.

(34:23):  Bedside commode to assist with toileting.

(35:44):  Ted Transfer Bench to make it easier to get in and out of bathtubs.

Transcript of Presentation:

(00:01): [Marla O'Keefe] Introduction. Hi, my name is Marla O'Keefe. Welcome to the workshop. Learn Rehabilitation Therapies to Manage Side Effects of Chronic Graft-versus Host Disease. I'd like to thank Kadmon, a Sanofi Company whose support helped make this workshop possible.

(00:17): It is my pleasure to now introduce today's speakers. Paulette Taku, Carly Cappozzo and Rachel Petrie. Paulette Taku is a senior physical therapist at the University of Texas MD Anderson Cancer Center. She is the lead physical therapist for the Stem Cell Physical Therapy Rehabilitation Program and the Chronic Graft-versus-Host Disease Clinic.

(00:43): Carly Cappozzo is a senior occupational therapist at The University of Texas MD Anderson Cancer Center. She developed MD Anderson's first chronic GVHD rehabilitation program and she collaborates with a multidisciplinary team of GVHD specialists each week to evaluate and treat GVHD patients from around the world.

(01:07): Rachel Petrie is an occupational therapist at the University of Louisville James Graham Brown Cancer Center. She works with patients and their families to address functional needs and educates them how to achieve independence using adaptive equipment and energy conservation.

(01:27): Overview of Talk. Ms. Taku, Ms. Cappozzo and Ms. Petrie have created a video to demonstrate exercises and assistive devices that can help patients relieve some of the symptoms of GVHD. Following the video they are here live to answer any questions you may have. Please note that you can download the PowerPoint slides that show photos of the exercises and items they are demonstrating complete with instructions.

(02:01): [Paulette Taku] Hi, my name is Paulette Taku. I'm a senior physical therapist at MD Anderson Cancer Center. Today I'll be educating and demonstrating strengthening exercises to strengthen the core and hip muscles in patients with graft-versus-host disease from steroid induced myopathy.

(02:19): What is steroid-induced myopathy? Corticosteroid induced myopathy, also known as steroid induced myopathy, is one of the side effects from prolonged use of taking glucocorticosteroids. That is a drug used treat patients with graft-versus-host disease. This condition is defined as muscle weakness, particularly in the muscles involving the hip and core regions. The elderly population has a higher risk of getting this condition due to having a lower baseline level of muscle mass. In addition, women are more prone to having it compared to men.

(02:57): Steroid-induced myopathy can make it difficult to rise from a seated position, climb stairs and reach overhead. Onset, symptoms and therapy. The onset for corticosteroid induced myopathy can range from weeks to months after taking glucocorticosteroids. Common complaints with corticosteroid-induced myopathy are difficulty rising from a seated position, climbing stairs and trouble with overhead activities. Physical therapy sessions consisting of cardio and strengthening exercises are effective ways at treating muscle weakness from corticosteroid-induced myopathy.

(03:30): Exercises patients can do to strengthen their hip and core muscles include isometric hip flexion - alternating, clam shells, marching, sit to stand and bridges. Common exercises patients can do to strengthen their hip and core muscles include isometric hip flexion - alternating, clam shells, marching, sit to stand and bridges.

(03:45) Demonstration of Isometric Hip Flexion – Alternating exercise to strengthen core muscles. This exercise will help strengthen your core muscles, which allow you to stand up from low surfaces with less difficulty. First, you will lay on your back with your knees bent at 90 degrees of knee flexion and you're going to raise your right leg up to 90 degrees, put your hand up on top of the knee and you're going to press forward for about three seconds. And then you'll bring your leg back down and switch to the opposite leg. Again, press for three seconds. You'll continue to alternate right and left until you've reached about 10 reps. After you do 10 reps you will pause, take a rest break for about 10 to 15 seconds and then you'll repeat the exercise again 10 more times and then do a third set. I would like you to do three sets of 10 with this exercise.

(04:39): Demonstration of Clamshell exercise to strengthen hip side muscles. The next exercise we will do today is called clamshells. This exercise will help strengthen the hip side muscles. So first you will lay on your side with your knees bent and your feet stacked on top of each other. From there you will lift your top leg two to three inches up, hold it for about two to three seconds and then bring it back down. Rest. Do it again. Lift it up two to three inches high, hold it two to three seconds, and then back down. You will do 10 reps on this side, rest and then you'll follow with two more sets of 10 on this side. From there, you'll roll up to the opposite side and repeat the exercise.

(05:19): Demonstration of Marching exercise to strengthen front hip muscles and make it easier to get up from a chair. The next exercise today is called marching, which will be done in the chair. You will first raise your right leg up two to three inches, hold it two to three seconds and down, left leg up two to three inches, hold it and down. The purpose of this exercise is to strengthen the front hip muscles to help you get up from chairs with less difficulty. Again, you'll do 10 reps and then rest and do two more sets of 10.

(05:45): Demonstration of Sit-to-Stand exercise to strengthen the core and leg muscles and make it easier to rise from a chair. The next exercise we will do is called sit to stand. This exercise will help strengthen your core and your leg muscles to get up from chairs with less difficulty. First, you will start in a sitting position from a chair, or you can do it from the edge of your bed. You're going to stand up and then sit back down again. Again, you will do 10 reps, total three sets of 10. If it is too difficult for you to stand up from the chair, you can put your hands on the edge of the chair for leverage and push up into standing position.

(06:19): Demonstration of Bridges exercise to strengthen hip and core muscles and the back. The last exercise we will do today is called Bridges. You will start laying on your back with your knees bent palms facing down. From there you will lift your hips up in the air, hold it two to three seconds and then back down. Repeat let's hold it two to three seconds, and back down. The purpose of this exercise is to strengthen your hip and core muscles and the back.

(06:44): I hope you find these exercises to be very helpful. Next Carly Cappozzo will demonstrate stretching exercises for patients with graft-versus-host disease.

(06:54): [Carly Cappozzo] Stretching exercises can help people with chronic GVHD decrease stiffness, improve range of motion and decrease joint contractures. Hi there. My name is Carly Cappozzo and I'm a senior occupational therapist at MD Anderson Cancer Center. Today, I'm going to share with you some stretching exercises that can be helpful for individuals with chronic GVHD to decrease stiffness, improve range of motion and decrease joint contractures.

(07:15): The most effective way to improve joint stiffness, restricted range of motion and joint contractures is with sustained low intensity stretching. First of all, you might be asking why is stretching so important? So the primary joint and fascia manifestations of graft-versus-host disease include joint stiffness, restricted range of motion and joint contractures and through the research they've shown that the most effective way to correct that, and to prevent it, is to do a sustained low intensity stretch. So that's holding it for a prolonged duration, not a high intensity or anything severe, but a just-right kind of stretch. So that's also a good way to monitor for any range of motion changes related to graft-versus-host disease because it's easier to correct them right at the get-go versus once it's progressed significantly.

(08:02): Some tips to keep in mind today when we're going through these stretches. First, if you have fragile skin or dry skin, you might want to apply your dermatologist-recommended moisturizer before beginning, to help prevent any cracking or irritation of the skin.

(08:23): Sustained low intensity stretching means holding the stretch for 30-60 seconds or longer. For all of these stretches, we're going to be holding them for at least 30 to 60 seconds. So unlike the exercises that Paulette demonstrated earlier, we're holding them for much, much longer, but we're not doing as many repetitions. So for most patients, one to two times per joint per day is sufficient, but you need to hold it for at least 30 to 60 seconds. You can hold it for longer and that is even better, but minimum 30 to 60 seconds.

(08:52): Movements should always be smooth, no bouncing or jerking movements while you're going through them. And we'll go through a few ways to modify each of these stretches today but take into consideration what your needs and limitations are.

(09:07): So if you have difficulty with your balance, you might opt to do some of the seated or lying down stretches versus some of the ones that are done standing. And if you're at home, you'll have easy access to maybe a chair or a table versus if you're in the hospital, you might have to adapt for those circumstances.

(09:27): Mild discomfort with stretches is OK; pain is not. The other thing is that we don't want any pain while doing stretches. So discomfort is okay and good. You want to be feeling the stretch, feeling a little discomfort, but never any pain. If you're feeling pain, you might be pushing a little too hard, so ease up a little bit, breathe, take a nice, slow, deep breath and focus on sending that breath right to the area of tension and then release your breath and release the tension from that point.

(09:56): Demonstration of Shoulder Flexion stretch to help with reaching overhead. So, the first stretch we're going to do is called shoulder flexion. This is important for helping you to reach overhead, to get things from upper cabinet shelves or to put on a shirt. So you'll start from a seated or a standing position. Raise your arm up straight in front of you with your thumb pointed up towards the sky, keep your elbow extended straight and keep your elbow close to your ear. Don't let your arm rotate out toward the side. You can do this with your other arm assisting you to get a deeper stretch or you can use a wall and kind of walk your fingers up the wall to get a little higher. You can do one arm at a time, or you can do both arms simultaneously. To get a deeper stretch lean in toward the wall slightly. You should feel this stretch down the back of the arm and maybe down the side.

(10:49): So, the alternative position for the shoulder flexion stretch will be lying flat on your back. You're going to raise your arms up straight overhead and clasp them with your elbows straight, gently let them fall up over your head toward whatever surface you're lying on. If you want to deepen the stretch, you can hold something in your hands to give a little extra pull toward the surface. Again, you should feel this stretch along the underside of the arm and along your sides. Hold this for 30 to 60 seconds at least.

(11:27): Demonstration of Chest Opener stretch for chest muscles and front of shoulders. The next stretch is called a chest opener and it's designed to stretch your chest muscles and the front of your shoulder. You're going to stand next to a wall, preferably at a corner or the edge of the doorway, but any wall will work. Raise your arm up to shoulder height and place your forearm and hand on the wall. You're going to then turn away from your body. Make sure you keep your shoulder rolled backward, not hunched forward and then you can adjust the height of your arm on the wall to stretch different parts of your chest, upper and lower. To deepen the stretch further you can take a step forward with your foot or just rotate your body slightly further. Again, you'll be holding this for at least 30 to 60 seconds.

(12:16): So the alternative position for the chest opener stretch is going to be lying flat on your back. Raise your arms straight up overhead with your palms facing one another and let them gently fall straight out toward the sides towards the surface you're laying on. If you'd like to get a deeper stretch, you can hold something in your hands, like a lightweight dumbbell or water bottle, whatever you have available. Hold this for at least 30 to 60 seconds.

(12:44): Demonstration of Wrist Extension and Wrist Flexion stretches to help with grasping items, typing on a keyboard and putting weight on hands. This next stretch is called wrist extension and this movement is important for reaching out to grasp items, for typing on a keyboard and for putting weight through your hands, such as when you're pushing up from a chair or on your hands and knees. So you'll start from either a seated or a standing position. Put your arms straight out in front of you with your palms up. And you're going to bend your wrist and fingers downward toward the ground and assist that movement with your opposite hand. With your elbow extended, like Paulette has here, you'll feel more of a stretch. If that's too intense, you can bend your elbow slightly to loosen up on the stretch. You're going to hold this for 30 to 60 seconds. Then repeat on the opposite side to do your opposite wrist. You should feel this going all the way along your forearm. If you have your elbow extended, you should feel it crossing the elbow joint.

(13:40): So, this is the alternate position for a wrist extension stretch. You're going to start with any flat table, chair, anything that you can put your hands onto and you're going to put them flat with your fingers extended, keep your elbows extended and you're going to gently lean forward to deepen the stretch through your wrist and forearms, hold this for 30 to 60 seconds and then relax and repeat.

(14:10): This next stretch is called wrist flexion and it will be stretching your wrist in the opposite direction as the previous one. So from a seated or standing position, hold your arms straight out in front of you with your elbow straight and put your hand in a fist. Your palm will be facing the ground. You're going to then bend your hand down toward the ground and use your opposite hand to give a little bit of pressure, feeling the stretch along the back of the forearm and the back of the hand as well. To make this stretch a little bit easier, you can extend your fingers straight out. Another way to make it less intense will be to bend the elbow slightly. You're going to hold this stretch again for 30 to 60 seconds, at least, then repeat with the opposite hand.

(15:04): Demonstration of Hip External Rotation stretch to help with getting in and out of a vehicle, climbing stairs and reaching your feet. So, this next stretch is called hip external rotation. This will help to stretch out the outer hip, which is important for activities like getting into and out of a vehicle, sitting down, going up and down stairs and reaching your feet to get dressed. So you'll start seated on a chair or at the edge of your bed and you're going cross one leg over the other with your ankle just above your knee. To deepen this stretch you'll push down gently on the crossed knee to try to get it parallel to the floor. The other way to deepen the stretch is to lean forward slightly, making sure that your back is flat and not rounded. You're going to hold this for at least 30 to 60 seconds breathing the entire time and then relax and repeat with the opposite leg. If you can't cross your leg all the way over the opposite knee, you can cross it lower on your leg, crossing it at the ankle joint or mid shin, whatever will give you a good stretch without feeling any pain in your hip. Hold it right there for 30 to 60 seconds.

(16:12): Demonstration of Ankle Dorsiflexion stretch which is important for walking without tripping, going up and down stairs and pushing down on the gas pedal of a car.  Next we're going to do a stretch called ankle dorsiflexion. This will stretch out the front and the back of your ankle, which is important for walking without tripping, going up and down stairs and pushing down on the gas pedal of a car. So you're going to start from a seated position, either in a chair with a footrest, sitting on your bed or seated on the floor. You're going to extend your legs straight out in front of you and wrap a towel or a strap around the ball of your foot and pull gently back toward your body. If you straighten your knee all the way, you'll feel this stretch all the way along the back of the leg. To deepen the stretch you can pull slightly harder to a point of tension, but not pain, or lean forward slightly, making sure to keep your back completely flat. It is nice to have back support while you're doing this, especially if you're very tight. So seated on a chair or up against something will be helpful. Hold this, breathe, relax for at least 30 to 60 seconds, then repeat with the opposite leg.

(17:30): Demonstration of Side Body stretch to help with reaching overhead and getting dressed. Next we're going to do a side body stretch. So this is important for reaching overhead and getting dressed. You're going to start from a seated position, preferably in a chair, and you're going to reach one arm up overhead and bend your body slightly toward the side, making sure you're not leaning forward, backward or rotating while you're doing this. You can hold your opposite hand on the bottom of the chair or on the armrest of the chair, if there is one, for some stability. Hold this for 30 to 60 seconds and you'll feel the stretch all the way down the arm through the armpit and the side body. Then you'll repeat with the opposite side.

(18:16): Demonstration of Trunk Rotation stretch to help you look over your shoulder or behind you, such as when driving a car. The last stretch we're going to show you today is called trunk rotation. This will help you to look over your shoulder or behind you, such as when you're driving a car. You'll start seated on a chair. You're going to put one hand on your opposite knee on the opposite side of it, and then turn your body to look over your shoulder, rotating your shoulders from where your hips are aligned. Make sure you're not leaning forward or backward while doing this. You're staying with good posture sitting up nice and tall, and you can put your opposite hand on the back of the chair, the seat of the chair or the armrest of the chair to help deepen the stretch. Make sure you're breathing while doing this. You should feel yourself pulling slightly back toward the front as you inhale, then deepen the stretch as you exhale. Hold this for 30 to 60 seconds, then repeat toward the opposite side.

(19:19): Thank you so much for the opportunity to share these stretches and exercises. I hope that you found them helpful. Next, Rachel Petrie will be demonstrating some adaptive devices to improve safety and function in patients with GVHD, as well as some splints and cast to improve range of motion and positioning.

(19:39): [Rachael Petrie] Adaptive devices are designed to help you remain independent, save energy, maintain safety, reduce falls and reduce frustration while doing daily tasks. Hello there. My name is Rachel Petrie. I'm an occupational therapist at the University of Louisville Hospital in Louisville, Kentucky. Today I'll be talking to you about adaptive equipment and splinting and casting for chronic graft-versus-host disease. Adaptive equipment is basically where someone has looked at a problem and come up with a solution. The idea is that you can remain independent with all of your daily activities, save energy, maintain your safety and prevent falls and reduce frustration.

(20:06): Whenever you're starting to use adaptive equipment, or a new tool, please remember that it's a learning process. Give yourself time and patience so that you can learn how to use this tool. It might be frustrating at first, but remember, the overall goal is to keep you independent and safe and save energy for things that you want to do.

(20:25): Some of the adaptive equipment that I'll show you today might be covered by insurance, so check with your provider or your insurance company. If not, you can purchase several of these items online through Sammons Preston, for example, or Amazon, or Performance Health, Inc. All are online companies that sell a lot of this equipment. Otherwise, if you want to go in-person shopping, Walmart or Walgreens or any of the medical supply stores carry several of these items as well.

(20:49): Splints and casts, fabricated to meet an individual’s needs, can help improve finger, wrist, elbow, shoulder and ankle extension and flexibility. So, in this next portion, we'll talk about splinting and casting. I'm just going to show a few different splints and casts. However, all of these items can be fabricated to the individual's needs. If there's something particular that we don't go over today, please get with your physician or your occupational therapist to come up with a solution.

(21:10): We know that chronic graft-versus-host disease can really limit extension. So that means bringing your fingers back or straight, same with your elbow or shoulder. It can also affect your ankle, which sometimes, as the fascia lays back down, it tends to restrict motion and make things seem really tight. I know you all have already heard from Carly and Paulette on stretching and strengthening. So this is just another intervention that we can use to help stretch some of the fascia to improve range of motion, to improve function.

(21:46): Make sure the splint or cast is not rubbing skin raw or causing numbness or tingling. Some of the splints that we'll talk about you can take on and off, they're all Velcro. The most important thing with all of these devices that we'll talk about today is to check your skin to make sure that the splint or cast is not rubbing you red or raw anywhere, not creating any area of pressure or any adverse reactions, numbness, tingling, anything like that. If any of that occurs, please discontinue the use of the device or the splint or cast and talk to your occupational therapist about it.

(22:16): Casts and the splints can be remolded to give you a better stretch, a longer stretch, as your motion improves over time. The idea behind these things, especially the cast, is that it goes all the way around the extremity or the area that's affected by the fascia limitations, so it creates a warmth. And that way it can cross several different joints, which really stretches out the fascia, so we can get a good stretch and really improve your range of motion. The cast and the splints can be remolded and can give you a better stretch, a longer stretch as your motion improves over time.

(22:47): If GVHD is affecting your vision, a free phone app called Seeing AI can be programmed to recognize faces and places, and can read aloud printed material and information contained in barcodes. So this device, I'm not going to be demonstrating, but it's a free app that you can download on your cell phone. It's called Seeing AI. So if you have chronic graft-versus-host disease that affects your vision, this might be something beneficial for you. Microsoft makes this and it is free., You can download it for most any of the devices. I have it downloaded on my iPhone. It's really nice because it has facial recognition, environmental recognition, barcode, so you can take it to the grocery store and hold it up to any type of food item and it will read aloud the barcode for you.

(23:21): You can program it to recognize different faces of people in your family, it can scan the environment and tell you where it thinks that you are. It can also read text if you want. Hold it up to a piece of paper, it can read aloud all of that for you. It can identify money, lights, colors, and even handwriting. So it has a lot of functions. Especially because it's a free app, I would definitely recommend checking that out.

(23:46): Demonstration of the BirdRock Grabber to reach and pick up small, large and heavy items, and assist with getting dressed. The first piece of adaptive equipment we'll be going over today is the BirdRock Grabber. I'm going to have Megan demonstrate this for you. This item is really good for if you have different restrictions with your motion in your shoulders, especially. You can pick up heavy items. This one has a nice gripper to it with suction cups, so you can reach up high, you can reach down low with even a heavy item like a can.

(24:09): You can also pick up small items from the ground, if you drop something. That way you don't have to bend over, you can grab something really small and pick it up.

(24:18): You can also use it to put on pants and clothing if you have any type of restrictions in your lower legs or hips. I'm going to have her practice putting on some pants. You'll just use the Reacher to be your bend, and then go ahead and use the grabber portion to pull it up your leg.

(24:37): Demonstration of the Freedom Wand that makes shaving, toileting and showering easier. This next item is called the freedom wand and it's multipurpose. You can carry it in your bag. It comes with a nice goody bag to keep everything in it. So you can keep it in your purse, take it on the go and it's multipurpose, which is nice also. To put it together, you'll snap it in place and then on the backside it has a lever, which will bring out these tongs here.

(25:02): The first thing I'll show, you can put a razor in it. You just put it right here and then you use that lever arm to make sure it's nice and sturdy there for you. And then you can adjust the position so you can go ahead and shave your legs, or you can also shave your underarms and depending on the way you position the lever and the way that you hold it in your arm, you can shave your face or your underarms. Go ahead and take this out for me using that lever arm again.

(25:36): Most people really like this device for toileting. You can do all of your hygiene, if you have hard to reach areas, or if you have any type of range of motion restrictions in your shoulders or your legs, or if you have kind of a larger size and it's just hard to reach in general. You'll do the same similar thing. You'll put your wipe or toilet paper down here in the lever again and make sure it's nice and secure. Sometimes that'll happen, it'll just fall right out, so you want to make sure it's nice and in there, and then use your lever. You can stand up and you can reach behind you and it's kind of giving you a longer arm, that way you can reach, or you can go in front and do the same thing.

(26:17): You can also put a loofah in there, if you want to take this item in the shower, so you can reach your back like she demonstrated. Some people like to use this to apply lotion, but I have another device that I would recommend for that instead.

(26:29): Demonstration of a Lotion Applicator that enables you to apply lotion in hard-to-reach areas without help from another person. This is the lotion applicator. It's nice because you can make it longer or shorter. All you have to do is twist and pull. It's really easy to use and then you lock it in place. You can also change the angle of this. If you push this button here, you can lift up or down, just depending on which area that you are putting the lotion on. You can also pull this out so that you can clean this device and then snap it right back on. It also comes with replacement roller pads so that you have multiple and can order new ones once it runs out.

(27:06): But you can apply all of your dermatologist-recommended lotion onto here, and it rolls on really nice and easily and use the lever arm if you have some range of motion restrictions. So you can go ahead and practice it on your legs. So without having to bend over, this can be your arm and you can put all of the lotion on without having to bend and use your energy to do that. This device can be really helpful for that. You can also do your upper back and lower back without having to strain. You don't need a second person to apply your lotion, you can put it all on by yourself using this device.

(27:41): Demonstration of a Slippie Gator and a Sock Aid to help put on compression sleeves and stockings. This next item is called the Slippie Gator. It comes in different sizes, and you can use it for arms or legs. This one is a large arm sleeve. So what you will do is put it on your arm, just like this and then you will slide on your compression sleeve and then pull it straight off. The manufacturer that makes this also recommends having a glove to put on, that way you can stick here and kind of pull it up a little bit easier, but you don't have to necessarily at all. And I would usually recommend people to make a fist while they have their hand in this device, it makes it a little bit easier to pull it up the arm with the compression, but it's a lot easier to put on this compression stocking with this device compared to trying to inch it up without something. So it saves a lot of energy using this.

(28:35): This next item is called a Sock Aid. The same idea, it helps you to save some energy and also you do not have to bend over or bring your leg up. This is going to act as your arm for both of those. What you'll do is put your sock on over top of this device and you'll make sure that the sock is completely flush up against there. It just helps it to slide on your foot in place a little bit easier. And once you have your sock all the way on, you'll use the ropes to toss it on the ground. You'll slide your foot into the sock aid, point your toe down and use the ropes to just pull up slowly and that will don your sock for you. You don't have to pull your leg up like that, you can just drop one side of the ropes and still grab it without having to bend your leg or your hips at all.

(29:23): Demonstration of Strain-Free Gripper Opener to make it easier to open jars and bottles. This item is called a Strain-Free Gripper Opener. It's nice because you can adjust the width so you can open different size items. You can open a can of jelly or a jar of jelly, and also a small bottle just like this. We're going to practice two different demonstrations today. You'll use this top lever here, you'll rotate it and that adjusts the sizing here on this side. Then once you have it secure in place, you use a longer lever arm, so you're going to be using more of your shoulder and your elbow to help do the force of opening those things.

(29:58): In order to open something larger, you want your mouth to be all the way open on these four prongs, and then you'll go ahead and put it on top, tighten the top lever to make sure it's nice and secure, and then use your arm to push forward to open up the jar lid. And it's much easier for you using those larger joints, as opposed to trying to use your fingers, especially with chronic graft-versus-host disease. We know that a lot of times we don't have that strength because of different restrictions. So then to release it, you're just going to pull on your lever and it will open up again.

(30:35): This bottle of water is not actually open yet. I'm going to have her practice opening this one, that's brand new, to show you. And if you didn't have another hand that had that much mobility in the wrist, you could also put it in between your legs or hold the bottle or jar in between your arm and trunk there.

(31:13): Demonstration of splints and casts that help stretch muscles. I'm going to show you a couple different splints and casts that you can use for graft-versus-host disease. You'll want to consult with your physician and your occupational therapist to decide which would be best for you, but we know that as the fascia lays back down, sometimes it can impair a range of motion, especially in the wrist, fingers and elbow joints.

(31:30): There are several different options, and this is by no means an exhaustive list of these devices and splints. We can custom anything for what the person needs.

(31:41): Demonstration of Hand-Based Paddle Orthosis splint to give fingers a good stretch. This one here is called a hand-based paddle orthosis. The idea behind this one is that it keeps your fingers nice and straight while moving your wrist up and down, and your elbow is free as well. So you can either slide your hand in or you can strap around each joint. So there's going to be one that's right above the wrist, one for the thumb, one that goes across the knuckles and one here more at the lower tips of your fingers. You can still move your wrist freely, but it gives your fingers a nice, good stretch.

(32:15): The next three casts that I will show you are a little bit different than the splint. They go all around the arm. So it incorporates your whole arm, fingers and ankle, just depending on what we're making on you, but the idea is that it crosses several different joints and areas in your body, so it can really stretch out and elongate that fascia, which will give you more range of motion after you wear this device.

(32:38): Demonstration of removable cast called the Hand and Finger Intrinsic Plus that stretches the wrist, fingers and thumb. This one is called a hand and finger intrinsic plus. It keeps your wrist and fingers in a good position with your thumb open as well. We'll slide on. You can also have it cut so that you can totally open it and close it and you'll strap the thumb, the wrist and the forearm. You can still move your elbow and your shoulder, but you'll have your wrist, and your fingers open into extension while it's stretching your thumb as well.

(33:13): Demonstration of removable cast to improve elbow extension. This one is for elbow extension. Again, you can slide your arm in, or you can also have it open and do one on top and one on bottom and then strap in place. Sometimes we'll also tell people to adjust how tight they're strapping their splint so that they can get used to some stretch over time. And gradually, as they're able to tolerate more of a stretch, they tighten those straps a little bit tighter over time. So your wrists and fingers are still free with this one.

(33:50): Demonstration of ankle cast to help with ankle flexibility. This next one is an ankle cast. You can slide your leg in or a lot of times we'll cut it in half and you'll strap it in place. But with all of these casts, you can take them on and off every day, you can clean your skin, apply your lotion, make sure that there's no adverse reactions from any of the casts or splints that you're wearing. But this keeps your ankle in a good position so that you're not getting a contracture down, so that you're not able to lift up your foot, which is a motion that you need for walking.

(34:23):  A bedside commode can be placed anywhere in the house to assist in toileting. You can use it, you can put it anywhere really, in your kitchen, living room, wherever. If you're especially having urgency and you need to get to the bathroom quick. Or if you're having GI issues with your chronic graft-versus-host disease, sometimes you need to use the bathroom quickly. And this will help falls so that you have something really close by. It's pretty easy to lift up and down. It's adjustable here at the feet, so you can make it higher or lower, depending on how tall you are. This one actually is a drop arm, which is nice. So if you're in a wheelchair, you just push this lever and it drops down, makes for an easy transfer back up.

(35:01): If urgency is not really your issue, you can also put it over top of a standard toilet. All you have to do is remove this bucket that's in here. So you can also put it over top of a normal toilet. So you'll just lift it and put it right over top here and this way you can stand up and down and you have something to reach back for and push up from, so it makes it a little bit safer and it's not quite so low to the ground.

(35:25): Okay, Megan, go ahead and come in and demonstrate this. So you'll come right over and you can reach back for the commode handles and lower yourself down nice and slowly, so you don't plop onto the commode and then you can push yourself back up. So it makes the toilet a little bit higher, easier to sit and stand up and down from.

(35:44): Demonstration of a Tub Transfer Bench to make it easier to get in and out of bathtubs. This is a Ted Transfer Bench. A lot of falls happen in the bathroom, especially getting in and out of the bathtub. So I really like this device for safety and fall prevention. So here Megan is going to demonstrate this for you. So she'll scoot back, she'll bring her legs in, one at a time to the bathtub, and then she'll scoot over just a little bit more. And now she's safely in the bathtub and ready to take a shower. 

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